Genital Tract Infection: Causes, Diagnosis, and Treatment

1. Genital tract infection By Dr. Nadia AL.Assady F.I.B.O.G C.A.B.O.G

2. Introduction

3. Are one of the most common reasons for women of all age groups to present to medical practitioner. • It is important to differentiate normal physiological changes from true infections. Thus, a good history & examination with lab, testing is fundamental before diagnosis is made.

4. The vaginal epithelium is lined by stratified squamous epithelium during the reproductive age group under the influence of oestrogen. The PH is usually between (3.5-4.5) • The lactobacilli are the most common organism present in the vagina . after the menopause the influence of oestrogen is decline making vaginal epithelium with more alkaline PH of 7 the lactobacilli conc. ,decline & the vagina is colonized by skin flora.

5. The physiological discharge occur in response to hormonal levels during the menstrual cycle . its usually white & changes to a more yellowish colour due to oxidation on contact with air. • There is increased mucous production from the cervix at the time of ovulation followed by thicker discharge (cervical plug) under the influence of progesterone • The discharge mainly consist of mucous desquamated epithelial cells , bacteria ( lactobacilli ) & fluid.

6. Lower GT Infection • Vulvovaginalcandidiasis: • Its caused by infection with a yeast-like fungus, the most common being candidaalbicans. • Its STDs & C. albicans is common commensal in the gut flora.

7. Predisposing factors: • 1-pregnancy • 2-high dose COCP • 3-antibiotics • 4-immunosuppresion • 5-HRT • 6-HIV • 7-DM • 8-anaemia

8. Symptoms: • 1.may be carried a symptomatically. • 2.vulval itching & soreness. • 3.dysuria & superficial dyspareunia. • D.DX: • 1-contact dermatitis. 2-allergic reaction. • 3- non specific vaginal infection.

9. Diagnosis: • 1-characterstic appearance of: • a-vulval & vaginal erythema. vulval fissuring. • b-typical white plaques adherent to the vaginal wall. • 2-wet film: microscopic detection of spores & pseudohyphae. • 3-culture from perineal & HVS & LVS.

10. Complication: • Its unlikely to cause any significant complications unless the women is severely immunocompromised

11. a-General : • 1.Avoid using any soaps & perfumes . • 2.Change the high dose COP to low dose COP if symptoms persist changes to POP. • 3.Cheek blood sugar to rule out any DM . • 4.Avoid recurrent courses of broad spectrum antibiotics

12. b-uncomplicated infection : • 1.Clotrimazol either single pessary (500 mg) or a course of (100 mg) pessary for (6 days). • 2.Flucanazol (150 mg) single dose orally. • 3.Itracanazol (200 mg) twice daily orally. • 4.Nystatin cream & pessary.

13. Notes: • 1.Topical imidazole have no adverse affect on pregnancy. • 2.Oral imidazole are contraindicated in pregnancy. • 3.No evidence for treatment of male partner. c-Complicated infection : • Its occur in acute sever infection.DM ,& immunosuppression • & here the topical treatment extended to up 2 weeks

14. d-Recurrent infection : • Its define at least 4 episodes of infection per a year. • The treatment include induction regimen to treat the acute episode followed by maintenance regimen to treat further recurrence, flucanazole (150 mg) is given in 3 doses orally every (72hrs) for the induction , followed by maintenance dose of (150 mg) weekly for (6 months).

15. Cure rate is (90%) at (6 months) ,& (40%) at (1 years) • In pregnancy topical imidazole can be used for (2weeks) than weekly dose of clotrimazole (500 mg) for (6-8 weeks). • Implications in pregnancy : • Its very common in pregnancy with no adverse affect • Topical imidazole not systematically absorbed so they are safe at all gestations.

16. Trichomonasvaginalis • Trichomonas is a flagellate protozon & can cause sever vulvovaginitis. Its usually STD & recurrence occur if the male partner is not simultaneously treated. It can cause UTI.

17. Symptoms: • 1.Asymptomatic carriers in (10-15%). • 2.Frothy yellowish greenish offensive smelling vaginal discharge. • 3.Vulval itching & soreness. • 4.Dysuria & superficial dysparunia & abdominal discomfort

18. Diagnosis: • 1.Cervix may have a "strawberry" appearance from punctate hemorrhage . • 2.Wet mount where the discharge is mixed with normal saline & examine under microscope show motile protozon. • 3.Culture on Diamond medium.

19. Complication : • There is evidence that Trichomoas infection may inhance HIV transmission.

20. Treatment: • 1.Both partners should be treated & screened from other STDs. • 2.Refrain from sexual intercourse until partner. • 3.Metronidazole (2gm) orally in a single dose or(500 mg) twice daily for (7days), this is should be avoid in the first trimester of pregnancy. • 4. Tinidazole (2gm) orally in a single dose. • Implications in pregnancy: • 1-preterm lobar 2- low birth weight

21. Bacterial vaginosis: • BV is an overgrowth of mixed anaerobes including Gardnerella & mycoplasma hominis which replace the usually dominant vaginal lactobacilli. Its not STDs but BV is reported to be more common with: TOP, IUCD, PID.

22. Diagnosis: • Amsel criteria: • a.Vaginal PH of more then 4.5, • b.Whiff test release characteristic fishy smell on adding (10%KOH) . • c.Microscopic detection of clue cells (squamous epithelial cells with bacteria adherent to their walls). • d.Creamy grayish white discharge . • There should be at least 3 criteria for the diagnosing BV Amsel criteria .

23. Hay /Ison criteria: • Grade1=normal :LB predominate. • Grade2=intermediate :LB seen with the presence of Gardnerella • Grade3=BV: LB absent with predominance of Gardnerella. • Complications: • It has been associated with risk of pelvic infection after gynae, surgery.

24. Treatment : • 1.metronidazole (400mg) orally twice daily for 5days or (2gm) as a single dose or intra vaginal gel applied at night for 5-7 days. • 2.clindamycin (300mg) twice daily or vaginal cream (2%). • Implications in pregnancy: • Mid or late 2nd trimester miscarriage. • PROM or preterm lobar.

25. Syphilis : • Its caused by Treponemapallidum a spircchaete. Infection occurs in 3 stages: • Primary syphilis: it occurs(10-90 days) post infection with painless genital ulcer(chancre) & inguinal LAP(enlarged groin

26. Secondary syphilis: occurs within the first 2 years of infection, generalized polymorphic rash affecting palms & soles, generalized LAP, genital condylomalata & ant. Uveitis. • Tertiary syphilis: present in 40% of people infected for > 2 year. neurosyphilis –tabesdorsalis & dementia. • CVS syphilis-- aortic aneurysm. • Gummata—inflmmatory plaques or nodules.

27. Diagnosis: • 1.smear from the primary lesion may demonstrate spirochaetes on dark field microscopy. • 2. serological testing :TPPA( particle agglutination), TPHA(haemagglutination assay), FTA(fluorescent trep .Abs.

28. Treatment: • 1-procaine penicillin (1.2 mu)daily I.M for 10 days. • 2-benzathine penicillin (2.4 mu)single doseI.M repeated after • 7 days. • 3-doxycycline(100mg) BD orally for (14 days). • 4-erythromycin(500mg)OD orally for (14 days). • 5-contact tracing. • 6-refrain from sexual intercourse until partner is treated

29. Implications in pregnancy: • 1-preterm labor 2-still birth • 3-congenital syphilis: IUD ,interstitial keratitis, 8th nerve deafness, abnormal teeth.

30. Human papilloma virus: "HPV" • Its DNA virus subtypes(6&11) cause genital warts (condylomataacuminata), subtypes (16&18) are associated with CIN & cervical neoplasia . • Symptoms: • The majority are asymptomatic , its may cause skin irritation or their presence may be embarrassing

31. Diagnosis: • The clinical appearance of lesion & cervical smear & colpscopy & biopsy of lesion. • Complication: • risk of high grade CIN & cervical neoplasia.

32. Treatment: • 1-podophyllin paint applied weekly . • 2- podophyllotoxin solution applied twice daily , 3days a week for 4 weeks . • 3-trichloroacetic acid repeated weekly . • 4-cryotherapy with liquid nitrogen . • 5-surgery (excision, diathermy or laser)

33. Implications in pregnancy: • Its tends to grow rapidly in pregnancy but regress after delivery • excision is not needed because highly vascular & cause bleeding • herpes simplex virus: • its DNA virus 2 types type 1(oral ) & type 2(genital).

34. Symptoms: • Primary HSV is usually the most sever & often result in flulike illness, inguinal LAP,vulvitis & pain(may cause urinary retention) • Small , characteristic vesicles on the vulva • Recurrent attacks are thought to result from reactivation of latent virus in the sacral ganglia & are normally shorter & less sever they triggered by stress , sexual intercourse, menstruation

35. Diagnosis: • The history & appearance of the typical rash. Swab from ulcer& serum from vesicles & culture . • Complications: • Meningitis, sacral radiculopathy(urinary retention&constipation transverse myelities & disseminated infections.

36. Treatment: • There is no cure for genital herpes, treatment just reducing the duration & severity of primary attack if given within 5 days of onset of symptoms. • 1-Acyclovir (200mg) 5times per a day. • 2-analgsia & local anesthetic gels & ice pack. • Implications in pregnancy: • Miscarriage , preterm lobar but no related congenital defects.

43. Thank you